 Thank you. Thank you. Thank you very much Ebony and all of the Indiana Ignite team for inviting me here to present some of our thoughts as to how we are moving forward particularly based on some of the work that this group has already been doing in one of our safety net hospitals in downtown Indianapolis also thank all of the Ignite Ward and of course Terry and Eric to invite me here to give a brief overview of what what is possible in a large health system if the health system were to adapt the principle that we could actually take genomic medicine and the findings of genomic medicine and try to make that part of our health system and health care process so just a brief overview some of you may be familiar with IU and IU Health what we have done over the last three years is to really create a seamless enterprise that has actually merged the the administration of the medical school and the administration of the hospital even though the hospital is a partially owned public corporation many of the senior officers including myself shared dual roles so I serve as the Dean for research at the School of Medicine but also the Executive Vice President for innovation and research in the health system so the concept here is that we are actually merging both the academic and the discovery mission to potentially health care mission and not that we are unique in that but there are very many schools that are trying to do that but I think one of the interesting aspects for us is that we do have a very huge reach and we essentially have the entire state as a possible laboratory to explore this opportunity so this just gives you a simple sort of overview of what IU Health is IU Health is one of the largest HBO's in the country probably think ranked as a seventh or eighth largest now it has about 19 hospitals that is spread across the entire state and covers about 3 million patient lives probably about 45 percent of the state so it's a very large health care system that has obviously several high-end academic medical centers in Indianapolis and surrounding areas but also very many tertiary I would say sites that are more critical care hospitals and affiliated with those are over a hundred community clinics and other types of service providers so it provides us with a very large canvas if you will and and as part of our clinical and translational sciences Institute or the which is another NIH funded program we've now created a very large sort of network of potentially both research but also what I would call academic types of service extensions so we have a single IRB system for all of these hospitals we have a single EHR in a data warehouse it's a CERNR based data warehouse that can essentially have data for all of these patients and then we have at each of these hospitals and many of these sites we have a space where patients can be consented patients the blood samples can be taken as well as a single laboratory system that that sends all of these blood samples to a central path lab and a central area for essentially high-end tests like genomic medicine and then we also obviously have a statewide bio repository that can collect samples and store them within the medical center so the infrastructure is implemented as is the the systems willingness to do that how do we we then went on to actually create joint goals a typical medical school goal of course is is to increase the number of programs number of funding NIH funding etc which is not always very meaningful to the hospitals they say yeah that's great but you know I'm more worried about revenue cycle and quarterly reports and patients flow and workflow so we've created a joint sort of goals for the enterprise but particularly we are focusing on accelerating clinical protocols within the system that particularly what we think would be beneficial to patients those type of protocols would be given priority and will become system goal what does it mean to become a system goal well essentially what it means is that most of our senior management's the CEOs of all these hospitals and the CFOs etc their compensation is about 40 to 50% based on performance and research becoming one these type of programs becoming one of the goals means almost 5% of their compensation depends on the success of these programs which provides an incredible motivation for the hospitals to actually make sure that they support the IT they support the infrastructure they provide space or the staff to do that so that's been part of the strategy here is to not only show the value of these types of innovations but also incentivize them to in some way make it happen at their sites so the areas that we are focusing particularly obviously these are the big areas for most hospitals and healthcare system to treat patients and and depend on their avenues but one of the cross cutting themes that with the we're thinking is extremely valuable is to focus on precision health obviously there are others such as you know population health which is more on health services and health outcomes related types of metrics but the the top one as you can see is precision health and we're defining precision health at least at this point primarily based on genomics types of information pharmacogenetics and other types of genomics as the the primary way of making it I would say more precise or a closer to precision at this point than anything else how are we moving this forward currently we as I said we're a CERNR shop so we have CERNR in all of the hospitals and is I would say about 40 to 45 percent of our non-hospital based clinical service areas and we're using a tool as if any of you are familiar with CERNR you know there's a tool called power trials within that that can actually tag patients that are either participating in a trial or potentially eligible for a trial and as I mentioned we are in the future our goal is to really have 20 impactful clinical trials that become preferred by the system and would become part of the system's goals and all of our physician practices all of our hospital CEOs will will be able to then create a platform for pushing out these these trials and once the patient is enrolled or consented there is a tag that shows up as this patient is participated in this trial or is it's potentially eligible for the trial the question of you know making physicians click on that if they're eligible is still a big challenge but certainly once they are eligible we we can enroll them and once they are enrolled they become tagged in the in the their patients electronic health record system and if any of the physicians that actually see this patient in any setting click on this then obviously you'll pull up the actual protocol they're on or even the consent and and and other documents that would be appropriate so by October and November period we're we're making the 20 impactful trial system wide but we have over seven that are now moving out and the number one as to as I hope to tell you would be the ingenious which is the ignite part of the trial we use the encore clinical trials software for actually entering the data so any patient that's enrolled in these trials will be entered into encore which is now directly connected to CERNR so every patient that's enrolled in any of these trials will automatically populate into CERNR the other thing that we can also do based on this encore tool is that if we put the inclusion and exclusion criteria for the clinical trial for the top trials that we select this will automatically search our electronic data warehouse and actually tag all the potentially eligible patients and we've just rolled out three trials so far and those searches can be done on a weekly basis and that list then goes to the study coordinators who would know where these patients are within the system and they're then able to let the exact facility know how to enroll these patients so as I mentioned one of the top trials we're moving forward with are the pharmacogenetic service to patients there are some other bio banking studies but our goal in the long run is to move 20 trials but the first one would be ingenious which is the part of the ignite trials I think you just heard that this is a pharmacogenetics based randomized control trial and the hope is that with the with at the end of this trial we will be able to show that there is significant cost savings and patient benefit using pharmacogenetically based decision support for particularly for prescription medications I think this is becoming increasingly valuable within our system as you can see this is the site that we use to actually educate providers engage patients or once they're enrolled they can get continued information about the about the trials might have seen this before but already we're beginning to reports the substantial actionable results and consultation outcomes but we hope this would be expanded to essentially a 2.5 million patients in addition to what's already been being done so our hope is that with this we'll actually be able to say as a health system we're providing precision health which you know we were broadly defining and for the system as both genetic but also behavioral and environmental factors while we're just at the beginning of some of the other components the behavioral and environmental component we certainly feel like we're in a place ready to move some of the genetic stuff forward and this is big again become also part of our entire university's I would say goal Indiana University is going to be 200 years old in 2020 so as part of the 2020 strategy precision health has become one of the grand challenge initiatives that the university has embraced which means that the the plan to invest substantial resources to create significant genomic discipline as well as some additional actionable items like cell and gene therapies by a lot the drugable genome and biological discovery based on that and of course significant data sciences and informatics so the idea is to really embrace this fully and make all of our health systems be part of a precision health environment over the next decade and and I say the two areas that we're already making substantial sort of investments one is in pharmacogenetics and and the second one is cancer genomics as you would expect this has become increasingly more and more part of our clinical care so we're beginning we're partnered with the couple of different areas to sequence gene whole genome whole exome sequencing of tumors and and then based on that refining our chemotherapy regimen so right now we have several hundred probably around 800 cancer patients that have gone through this within the last two years and already within our system we're seeing a substantial benefit to patients in terms of their survival curves those that have been treated with genomic based chemotherapy regimen versus those that are using standard usual care regimen and and this becomes part of the value that we can provide to our patients but it from the system level it also becomes a major market differentiator when you're trying to compete in a health care environment with other health systems in your market area so I think with we think this is a an important move forward and finally one of the things that we're beginning to see also is some some ways to address the health equity and health disparities one of the big exams surprising examples for us we're still analyzing the data is that it turns out that breast cancer outcomes have been in a reported uniformly poor as poor for African-American women as opposed to Caucasians and at least in our system what we're finding is that African-American women get much lower dose of tax all because of some of the potential side effects and that may well be one of the major reasons why they show poor outcomes because they don't get adequate high enough doses of tax all so we're beginning to now use pharmacogenetics to actually look at plasma levels to see if that can be addressed so there are many potential ways I think this this approach the at a halt system level can bring a lot of value and and and makes good science but also very intelligent business so that's what we're excited about and we look forward to partnering obviously with our academic partners and NIH and other interested parties to make this reality so thank you very much thank you another we have some time for questions it looks like hands are already raised we have Eric and then Dan sure hi that was very helpful thank you could you maybe just describe a little bit more I was trying to understand sort of how the CTSA funding that you get for this and one slide you sort of showed it in the center but I wasn't sure if this was sort of a critical part of it was sort of it was a really the center of the of your universe or is it just a component part like other sources of funding yeah so the CTSA has helped in several components of this one for example starting with the single IRB for our entire hospital system that was one of the things that we did through the CTSI the second area is the rolling out of Encore for all clinical trials which we worked with the University clinical trials office which is part of the CTSI so those are two big ones that we have already used the CTSI resources for and establishing some of our clear processes for genome testing at all of these sites sample transfer from multiple peripheral sites and setting up SOPs for those kinds of processes at all of these sites have all been part of the CTSI regulatory program that's helped with us so I think we know we have sort of leveraged the health system and the NIH investment in the CTSI very nicely to create that that whole network across the state and and the universities in our CTSI three of the university academic universities in Indiana our partners it's Indiana University but also Purdue University and Notre Dame and Purdue has a lot of process engineers who have helped us actually conduct a lean six sigma process to improve all of our process across the state so I had a sort of a question a similar vein and and maybe I can just sort of phrase it a bit differently and get a different sense of the answer of do you how much of an investment has the institution made the and for you the institution I guess is also the state and the CTSI and NHGRI can you sort of give us a numbers and and how so how much skin is does each of those players have in this game yeah yeah I mean I think you know I I can't give you the exact amount of NHGRI support I think that's that's pretty much through the Ignite program primarily I can't say the health system has made huge investments in this right now we provide probably about close to three million dollars a year to maintain this infrastructure across the 19 hospitals and this involves essentially staff of part-time nurses at these different hospitals space utilization as well as probably about a million dollars of that goes to the electronic health or our IT systems to to be able to do the required searches through the adw to pull out the the tracking and pushing out of the message and that's just the operating costs at this point we have obviously the the school is invested substantial amount in the precision health in terms of faculty development and faculty hires the other investments which are partially helping this are you know obviously the building out of the adw and connection to all of the electronic health records so while there is in kind support of several million dollars there's actual direct support of about three million per year and and the other thing that I would also mention is that this we were able to talk to the state legislatures about this and they were quite interested in this so we are through the CTSI we actually got a two million dollar line item in the state budget to help with this as well so there's there's substantial interest in investment in this yeah so I'm I'm sort of interested in the sociology of this of this whole process of embracing precision health could you describe you know whether you met with any resistance at all and what did you promise would be the results at the end to get you this type of investment that you've been able to achieve yeah the it is part of part of this is of course the promise of what we think would be better patient care and while you know one can say as Jeff you know you can say this is going to solve all human health and really going to find all kinds of cures for every incurable disease the short-term benefits really is even cost savings aren't a big deal for the health system they will say well you know if I'm putting three million dollars every year I could do that in another program and get you know three X returns very easily so I expect to justify that unless it's it saves me 15 to 20 million dollars it's not worth my time to put three million dollars so I think that's that's really not the only cell we can say that certainly is going to save you some major adverse events and major benefits but it'll be for a subs much smaller patient a population the biggest selling point for me was that this will be your market differentiator in the healthcare market so that more of the patients with these high-end sort of care-needing diseases like cancer like cardiovascular diseases like people with treatment resistant conditions will come to you rather than go to your competitors because you are able to even if you can't find the right treatment you're able to give them a better answer than the other health systems so that's been the biggest thing that's worked on the c-suites for me yeah I was kind of interested in the in a similar question but maybe in the practical sense I think you said something about incentivizing physicians for demonstrating innovation in genomic medicine broadly could you elaborate a little bit on how you measure that is it just enrolling people in immunology trials or yeah yeah so right now it's it's fairly crude so what we're what we're saying is that these top 20 trials will have enrollment metrics for each of the systems and those enrollment metrics are based on eligible patients within that system so every hospital or every clinic we can look at the EDWC what percent of patients are at least based on the inclusion exclusion criteria are eligible and our goal is to say if you have 10 eligible patients you would have been you would have met your satisfactory metric if you've enrolled at least one patient within out of that 10 and you would exceed your goal if you enroll two patients and that satisfactory metric actually determines 5% of the comp for many of the executives and also provides a research RVU for four physicians so we're still refining that system but it's relatively crude at this point so yeah if I could ask the research RVU is a very interesting approach to incentivizing physicians how how where do you get that money from to be able to provide it to them yeah so what we've said is that everybody in order to get their clinical pay they have to meet 80% of their clinical RVUs the remaining 20% is met by either teaching RVUs or research RVUs so you could do 100% clinical RVUs and not teach or not not do any research as affiliated activities but it's a lot easier for them to help recruit patients and get that 20% RVUs well and obviously it's very important for clinicians who want to do research when they're being really pressured to get the value units up for clinical care so yeah we think that's really the value it's a lot of our academic or clinical faculty feel actually that they are they're very excited to do this and they really even the hospital CEOs really want us to give us all kinds of information how to roll this out because they're all interested and excited it's mostly protecting time thank you very much as you see everyone was very excited to hear about the Indiana Health University thank you we next have Tony Poland who is a PI at the University of Maryland and she actually led a workshop engaging insurers and payers and other people from technology companies that was not even two weeks ago and she's just going to give us feedback I just want to let you know this preliminary feedback because she hasn't got the input and written up but she's going to give us feedback and what we heard that day thank you very much Tony